Cash all prizes of $599 or less at

participating Lottery Retailers

CLAIMANT INFORMATION PLEASE READ ALL INFORMATION AND INSTRUCTIONS BEFORE COMPLETING CLAIM FORM
LAST NAME DATE OF BIRTH - -
MONTH DAY YEAR

FIRST NAME MI SUFFIX SSN/TIN - -

ADDRESS 1

ADDRESS 2

CITY STATE ZIP CODE -

COUNTRY E-MAIL

PHONE - -
AREA CODE
For tax purposes only:
I am a Lottery Retailer I do not have a Social Security Number
I am employed by a Lottery Retailer I am not a U.S. Citizen, and I am not a Resident Alien
I am related to a Lottery Retailer

TICKET INFORMATION
Attach the original ticket to this form with your legal name, signature and address showing. Enter the
information below (Scratchers 13-18 digit ticket number is located on back of ticket; Draw Game 18 digit ticket number
is located on front of ticket). Attach another claim form for more than one ticket.

Ticket Number: Prize Claim: $

I declare, under penalty of perjury under the laws of the State of California, including but not limited to California
Penal Code §§ 118 and 72, that I am the rightful owner of the ticket on this form, that I am 18 years of age or
older, and that all information provided is true and correct. I understand that any person who, with intent to
defraud, falsely makes, alters, forges or counterfeits a Lottery ticket is in violation of state law and could be liable
for criminal penalties.

Claimant Signature Date

(Only one signature, and it must match signature on ticket)

FOR DISTRICT OFFICE USE ONLY FOR HEADQUARTER OFFICE USE ONLY
PLAYER I.D. CODE DIST. OFFICE CODE DATE RECEIVED POST MARK DATE
CODE(S)
DRAW DATE INITIALS REASON
RELEASED
CRN

CSL 1242 (R7/19) Page 1 of 3

 PRIZE PAYMENT INFORMATION
Failure to provide your original signed ticket with date of birth, legal name, complete address (including
apartment or space number, city, state, zip code), email and phone number may delay or prevent the
California State Lottery (Lottery) from processing your prize claim. Claims submitted to Lottery Headquarters for
processing are paid by check and mailed from the California State Controller's Office. Processing time, once claim
is received and verified, is approximately 8 weeks. If you have questions, contact the Lottery at 1-800-
LOTTERY (568-8379), Monday through Friday.
Lottery prizes are not subject to California state income tax. The Lottery is required by federal tax law to withhold
federal taxes of 24% for U.S. citizens and resident aliens. Non-US citizens will have 30% withheld from all prizes.

Tickets, transactions, purchases, claims and prize payments are subject to federal and state law and California
Lottery regulations, policies and procedures. Copies of regulations are available at Lottery District Offices and on our
website at www.calottery.com. Tickets failing validation are void.
INSTRUCTIONS
1. Print your legal name, street address, city, state, and zip code on the back of the ticket.
2. Sign your name on the back of the original ticket.
3. Complete the Claimant Information and Ticket Information sections on the first page of this form.
4. Sign the first page of this form with ink. (ONLY ONE SIGNATURE IS PERMITTED)
5. Staple your original ticket to the front of this form.
KEEP A COPY OF THIS FORM AND A COPY OF THE FRONT AND BACK OF THE TICKET.

Deliver the completed claim form with original ticket to any Lottery District Office. Location and
directions can be found at www.calottery.com.
OR, MAIL THIS CLAIM FORM, AT YOUR OWN RISK, WITH THE ORIGINAL TICKET STAPLED ON THE FRONT,
TO: California Lottery, 730 North 10th Street, Sacramento, CA 95811-0336
Call 1-800-LOTTERY(568-8379), or visit any Lottery District Office to request a Multiple Ownership Claim
form for group players (less than 100) sharing prizes of $1,000,000, or more.
PRIVACY NOTICE
The Information Practices Act of 1977 (Cal. Civ. Code §§1798-1798.78, the Federal Privacy Act (Public Law 93-579), 5
U.S.C. §552a, and Cal. Gov. Code §§11015.5 and 11019.9, require that this notice be provided when collecting
personal information from individuals.
The Claimant Information requested on this form will be used to validate and process your claim in accordance with
the California State Lottery Act of 1984 (Gov. Code §8880 et seq.). The Lottery requests a player's social security or
tax identification number (SSN/TIN) for tax withholding and reporting purposes, pursuant to Internal Revenue Code
§§6011, 6041, 6109, 3402, and the regulations enacted thereunder.
The Claimant Information you provide may be disclosed to various state and federal government agencies, including
but not limited to: the State Controller's Office, Franchise Tax Board, Health and Welfare Agency, and the Internal
Revenue Service. It will not be disclosed to members of the public.
You have the right to access your personal information maintained by the Lottery by contacting the California
Lottery, 700 North 10th Street, Sacramento, CA 95811-0336 - Attention: Privacy Coordinator, Information Security
Office - Security and Law Enforcement Division. The Privacy Coordinator can also be reached at 916-822-8800 or
privacy@calottery.com.
Purpose and Relevancy of Information Collected: Information is collected to validate and process a claim and for
purposes of sales, marketing, research, security investigation, legal review, surveys, and strategic planning as related
to the operations of the Lottery. By submitting this claim, you consent and agree to such use, and waive any and all
legal claims, known or unknown, related to the specified uses set forth herein. The California Lottery is subject to
public disclosure laws that allow access to certain governmental records. Your full name, the name and location of
the retailer who sold you the winning ticket, the date you won, and the amount of your winnings, including your
gross and net installment payments, are matters of public record and are subject to disclosure. The Lottery will not
disclose any other personal or identifying information without your permission unless legally required to do so. No
information will be collected or accepted from known minors. You may be asked to participate in a press conference.

CSL 1242 (R7/19) Page 2 of 3

VOLUNTARY DEMOGRAPHIC INFORMATION
By volunteering to answer the following questions, you will help the Lottery know more about its players. The
voluntary information that you provide regarding your ethnicity, household income, gender, and household
composition will be used only by the Lottery to conduct internal demographic analyses (which may be completed by
agents and contractors).
Which of the following do you consider Annual Household Income Gender
yourself to be? Under $30,000 Female
(Check all that apply) $30,000 TO $49,999 Male
$50,000 TO $99,999 Nonbinary
African American
Asian $100,000 TO $149,999
Hispanic $150,000 or more
White
Number of People in Household
Other (Specify)
(including yourself):

CSL 1242 (R7/19) Page 3 of 3